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SMALLPOX    and 

VACCINATION 


JAY  F.  SCHAMBERG,  M.  D. 

PHILADELPHIA,  PA. 


)JC 


PRESS    OF 

American  Medical  Association 

Five    Hundred   and   Thirty-Five   North    Dearborn    Street 

CHICAGO 


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A.    Journal    of   Individual    and    Community    Health 

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sion of  the  United  States 
presents  to  the  public 
interesting,  instructive 
and  authoritative  articles 
about  health 

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535  North   Dearborn   Street    -     CHICAGO 


SMALLPOX  * 


JAY    F.     SCHAMBERG,     M.D. 

PHILADELPHIA 


Smallpox,  perhaps  more  than  any  other  disease,  has 
inspired  fear  and  terror  in  the  popular  mind  because 
of  its  loathsome  appearance,  its  extreme  contagious- 
ness and  its  disfiguring  consequences. 

Lord  Macauley's  Description  of  Smallpox. — Lord 
Macauley,  writing  of  the  untimely  death  from  small- 
pox in  1694  of  the  young  and  beautiful  Queen  Mary 
of  England,  gives  us  a  powerful  pen  picture  of  the 
ravages  of  this  pestilence : 

That  disease,  over  which  science  has  since  achieved  a 
succession  of  glorious  and  beneficient  victories,  was  then 
the  most  terrible  of  all  the  ministers  of  death.  The  havoc 
of  the  plague  has  been  far  more  rapid,  but  the  plague  has 
visited  our  shores  only  once  or  twice  within  living  memory; 
and  the  smallpox  was  always  present,  filling  the  church- 
yards with  corpses,  tormenting  with  constant  fears  all  whom 
it  had  no,v  yet  stricken,  leaving  on  those  whose  lives  it  spared 
the  hideous  traces  of  its  power,  turning  the  babe  into  a 
changeling  at  which  the  mother  shuddered,  and  making  the 
eyes  and  cheeks  of  the  betrothed  maiden  objects  of  horror 
to  the  lover. 

Blindness  from  Smallpox. — During  certain  periods 
in  England,  a  very  large  percentage  of  the  people  were 
pockmarked.  Ben  Jonson,  the  Elizabethan  dramatist, 
wrote : 

Envious  and  foule  disease,  could  there  not  be, 
One  beautie  in  an  age  and  free  from  thee. 

Not  only  did  the  disease  destroy  life,  disfigure  and 
maim,  but  it  was  at  one  time  the  most  common  cause 
of  blindness.  The  early  records  of  the  London  Asy- 
lum for  the  Indigent  Blind  showed  that  two  thirds  of 
the  inmates  had  lost  their  sight  as  a  result  of 
smallpox. 

Smallpox  Adages. — Smallpox  was  a  great  scourge 
before  the  introduction  of  vaccination.  In  London 
during  the  eighteenth  century  it  caused  one  twelfth 
of  all  deaths.  Every  one  felt  that  he  had  to  pass 
through  an  attack  of  smallpox  at  some  period  of  his 

*  This  pamphlet  is  one  of  a  series  on  public  health,  prepared  by  the 
Council  on  Health  and  Public  Instruction  of  the  American  Medical 
Association  [1914].  Other  pamphlets  can  be  secured  from  the  American 
Medical   Association,    S'3S    North   Dearborn   Street,   Chicago. 


life.  One  of  Horace  Walpole's  correspondents 
(Walpole's  Letters)  wrote:  "Poetry  is  as  universally 
contagious  as  smallpox:  everyone  catches  it  once  in 
a  lifetime  at  least,  and  the  sooner  the  better."  The 
Germans  had  a  proverb  which  expressed  the  same 
thought :  "From  love  and  smallpox  but  few  remain 
free."  Most  children  in  London  contracted  smallpox 
before  the  aee  of  7. 


Fig.    1. — Normal    appearance    of    site    of    vaccination,    first    day. 


Extent  of  Smallpox. — In  the  City  of  London,  from 
1700  to  1800,  in  a  population  varying  approximately 
from  600,000  to  750,000,  there  were  only  nine 
years  throughout  the  century  when  the  deaths  from 
smallpox  declined  below  1,000;  taking  the  entire  cen- 
tury the  deaths  averaged  almost  2,000  per  annum.  This 
would  represent  more  than  10,000  attacks  of  small- 
pox annually,  as  less  than  one  in  five  victims  died. 
Smallpox  did  not  occur  in  epidemics,  as  at  present,  for 
it  was  present  continuously. 


EXPOSURE     TO     SMALLPOX 


Smallpox  Infection  in  Clothing. — Smallpox  is  one 
of  the  most  contagious  of  diseases.  The  infection  is 
usually   transferred   directly   from   one   individual   to 


Fig-    2. — Normal    appearance    of    vaccination    site,    fifth    day. 

another  through  the  atmosphere,  but  it  may  be  trans- 
mitted through  infected  clothing  and  other  objects 
In  the  smallpox  epidemic  of   1901-1904,  in   Philadel- 


phia,  a  number  of  cases  of  smallpox  broke  out  among 
the  salesmen  in  a  large  clothing  store ;  the  infection 
was  traced  to  a  window-dresser  whose  daughter  was 
suffering  from  smallpox  at  home,  and  the  contagion 
was,  beyond  reasonable  doubt,  carried  to  the  store  in 
the  infected  garments  of  the  father. 


Fig.   3. — Normal  appearance   of  vaccination   site,   seventh   day. 


Smallpox  Sufferers  Traveling  on  Trains. — Persons 
suffering  from  smallpox  in  the  early  stages  some- 
times travel  long  distances  on  railroad  trains.  On 
one  occasion  a  young  woman  heavily  veiled,  and  suf- 
fering from  what  later  proved  to  be  a  very  severe 
attack   of    smallpox,   traveled    in   a   day   coach    from 


Atlantic  City  to  Philadelphia  in  order  to  enter  a  hos- 
pital in  the  latter  city.  A  large  number  of  people  were 
exposed  to  the  infection  of  the  disease  without  sus- 
pecting their  danger.  I  have  personal  knowledge  of 
other  patients  traveling  hundreds  of  miles  on  railroads, 
while  in  an  actively  contagious  stage  of  the  disease. 
Such  experiences  are  a  sufficient  answer  to  those  per- 


4 


Fig.  4. — Normal  appearance  of  vaccination  site,  ninth  day. 

sons  who  lull  themselves  into  the  false  security  that 
they  can  avoid  exposure  to  smallpox. 

THE     MILD    TYPE    OF     SMALLPOX 

Different  Types  of  Smallpox. — Since  1896,  there 
has  been  widely  prevalent  in  the  United  States,  a  pecu- 
liarly mild  type  of  smallpox  which  kills  only  a  very 
small  proportion  of  those  attacked.  Hundreds  of 
thousands  of  such  cases  have  occurred  throughout  the 
country.  This  mild  type  is  doubtless  due  to  the  weak- 
ness  of  the   infecting  germ.     Two   entirely   different 


types  of  smallpox  have  prevailed  in  this  country — one 
the  virulent  imported  variety,  which  destroys  the  lives 
of  one-quarter  of  those  whom  it  attacks,  and  the  other 
the  mild  type  above  referred  to.  An  interesting  feature 
of  the  latter  type  is  that  it  is  not  only  mild  as  to  mor- 
tality but  also  as  to  its  contagiousness;  practically  it 


Fig.  5. — Normal  appearance  of  vaccination  site,  fifteenth  day. 

attacks  only  the  unvaccinated,  and  vaccinated  persons, 
even  if  the  vaccination  dates  back  thirty  or  more  years, 
are,  as  a  rule,  protected  against  it.  The  opponents  of 
vaccination  point  to  this  mild  type  of  smallpox  and 
say  that  the  disease  has  lost  its  terrors.  Those  who  are 
thoroughly  familiar  with  the  subject,  however,  know 


that  neglect  of  vaccination  may  prepare  a  community 
for  a  death-dealing  epidemic  of  the  classic  type  of  the 
disease. 

SMALLPOX    A    CRUEL    DISEASE 

Early  Symptoms. — -The  patient,  during  the  early 
stages  of  a  classic  attack  of  smallpox,  suffers  from  a 
pronounced  chill,  followed  by  sudden  fever  and  severe 
headache  and  backache :  nausea  and  vomiting  occur 
with  great  frequency  and  the  latter  may  persist  for 
several  days.  Dizziness  and  general  aches  and  pains 
are  common.    In  severe  cases,  there  is  great  weakness 


Fig.  6. — Infant  born  in  _  the  smallpox  wards  of  the  Philadelphia 
Municipal  Hospital.  Vaccinated  immediately  and  protected  against 
small-pox.  (From  Acute  Contagious  Diseases,  Welch  and  Schamberg; 
published   by    Lea    Bros.,    Philadelphia.) 


and  prostration.  During  this  stage,  while  the  symp- 
toms may  be  most  suggestive  of  smallpox,  no  positive 
diagnosis  can  be  made  as  the  "grip"  and  certain  other 
infections  may  imitate  the  early  symptoms  of  small- 
pox. Not  until  the  eruption  appears  can  one  be  abso- 
lutely sure  of  the  nature  of  the  disease.  Many  persons 
are  commonly  exposed  to  smallpox  before  the  diag- 
nosis can  be  definitely  established. 

Eruptive  Stage. — About  the  third  day  of  the  illness, 
the  fever  abates,  the  pains  subside  and  the  patient 
begins  to  feel  that  his  illness  is  at  an  end.     But  he  is 


8 


woefully  mistaken,  for  it  has  barely  begun.  At  this 
time  the  eruption  makes  its  appearance ;  it  is  not  for- 
midable at  first  sight  and  looks  not  unlike  a  multitude 
of  flea-bites  on  the  face,  hands  and  elsewhere.  Soon  it 
spreads  over  the  greater  part  of  the  body.  From  day  to 
day  the  eruption  undergoes  a  change  (see  Figs.  1-7), 
soon  the  face  is  covered  with  numerous  pustules,  the 


Fig.    7. — Typical    "take"    of   vaccination    showing   necessity    of    revacci- 
nation  at  intervals.    Patient  relied  on  previous  scar  as  showing  immunity. 


features  are  swollen  beyond  their  normal  proportions 
and  the  patient  disfigured  beyond  recognition.  The 
fever  again  rises  and  acquires  the  characteristics  of 
blood-poison  fever.  The  patient  suffers  greatly  from 
the  soreness  occasioned  by  the  multitude  of  pustules 
present,  particularly  those  on  the  hands  and  feet.  In 
severe  cases  the  pustules  may  reach  the  enormous 
number  of  30,000  to  40,000.     The  presence  of  small- 


pox  sores  in  the  nose  and  mouth  cause  great  difficulty 
in  breathing  and  great  distress  in  swallowing. 

The  Plague  of  Boils. — At  about  the  end  of  a  fort- 
night, the  patient  if  he  recovers,  has  passed  through 
the  height  of  the  eruptive  process,  and  is  led  to  believe 
that  he  is  on  the  road  to  convalescence.  Now  a  new 
plague  attacks  the  unfortunate  victim,  for  he  begins  to 
be  the  subject  of  boils  and  abscesses  which  may  num- 
ber but  a  half-dozen  or  may  reach  a  hundred  or  more. 
In  a  proportion  of  smallpox  cases,  which  varies  with 
the  severity  of  the  attack,  one  or  both  eyes  may  be  lost, 
with  consequent  impairment  or  loss  of  vision. 

An  attack  of  unmodified  smallpox  runs  its  course  in 
about  five  or  six  weeks.  At  its  conclusion,  the  patient 
exhibits  on  his  countenance  numerous  disfiguring  pits 
and  scars  which  remain  throughout  his  life  as  a  sad 
reminder  of  the  cruel  malady  through  which  he  has 
passed. 

Smallpox,  in  its  usual  form,  is  a  terrible  disease  and 
there  is  an  almost  universal  susceptibility  of  the  human 
family  to  its  infection,  but  there  is  no  malady  against 
which  science  possesses  a  surer  and  more  complete 
safeguard.  For  that  great  discovery,  the  world  is 
indebted  to  Edward  Jenner. 

DR.    EDWARD    JENNER,    WHO    INTRODUCED    VACCINATION 

Honors  Conferred  on  Jenner. — Dr.  Edward  Jenner, 
of  Berkeley,  England,  announced  to  the  world  in  1798 
what  was  later  generally  regarded  as  the  "greatest  dis- 
covery ever  made  for  the  preservation  of  the  human 
species."  Jenner  proclaimed  his  discovery  in  a  modest 
pamphlet  which  excited  the  attention  of  the  entire  civ- 
ilized world.  When  the  truth  of  his  conclusions  was 
established,  honors  fell  fast  on  him.  The  British  par- 
liament voted  him  $50,000  in  1802,  and  five  years  later 
a  second  grant  of  $100,000.  He  was  made  physician 
extraordinary  to  the  king  of  Great  Britain.  The  most 
distinguished  scientific  bodies  throughout  the  world 
vied  with  each  other  in  conferring  degrees  on  the  illus- 
trious but  modest  physician.  Within  twenty-one  years, 
Jenner  received  no  fewer  than  28  diplomas  from  insti- 
tutions of  learning,  and  within  a  period  of  six  years, 
eight  medals  were  struck  in  Europe  in  honor  of  the 
great  discovery,  one  of  these  being  the  most  beautiful 
of  the  Napoleonic  series.     Many  of  the  crowned  heads 


10 


of  Europe  addressed  complimentary  epistles  to  Jenner. 
and  a  letter  from  the  discoverer  constituted  the  best 
passport  through  foreign  countries  in  time  of  war. 


Fig.  8. — Two  children  in  the  Municipal  Hospital  of  Philadelphia,  in 
1913.  One  unvaccinated,  the  other  vaccinated  on  the  day  of  admis- 
sion. Crust  of  vaccination  still  seen  on  leg.  This  child's  mother  had 
smallpox  and  child  remained  with  her  in  the  hospital  for  three  weeks: 
was  discharged  perfectly  well.  The  unvaccinated  child,  admitted  with 
smallpox,  died.  (From  Acute  Contagious  Diseases,  Welch  and 
Schamberg. ) 

THE    CLAIMS    FOR    VACCINATION 

Duration  of  Protection  After  Vaccination. — A  recent 
successful   vaccination   will  confer  protection  against 


.5  <o       3 

^_  »«  2 
■a  «  5 


12 

smallpox  in  at  least  ninety-nine  out  of  one  hundred 
individuals.  An  infant  successfully  vaccinated  can  not 
contract  smallpox  even  though  it  be  placed  in  bed 
with  a  person  suffering  from  this  disease.  This  has 
been  abundantly  proved  in  every  smallpox  epidemic 
in  every  country.  After  a  lapse  of  five  or  ten  years, 
the  susceptibility  to  smallpox  may  in  part  return,  and 
the  individual  may  require  revaccination  to  reestablish 
immunity  against  smallpox.  An  attack  of  smallpox, 
scarlet  fever,  measles  or  chickenpox  leaves  in  the  sys- 
tem a  protective  substance,  which,  in  the  vast  majority 
of  instances,  safeguards  the  individual  against  a  second 
attack.  There  are,  to  be  sure,  some  highly  susceptible 
subjects  in  whom  the  immunity  is  not  permanent  and 
who  may,  on  future  exposure,  contract  a  second  attack 
of  the  disease.     Second  attacks  of  smallpox  are  rare. 

Hozv  Vaccination  Protects. — Vaccination,  which  is 
the  result  of  the  inoculation  of  a  virus  closely  related 
to  smallpox,  protects  against  the  latter  disease  much 
in  the  same  manner  as  one  attack  of  smallpox  confers 
protection  against  a  second,  save  for  the  fact  that  the 
immunity  is  not,  as  a  rule,  of  so  long  duration  and 
requires  renewal.  It  is  not  claimed  at  present  that  a 
single  vaccination  will  invariably  protect  against  small- 
pox for  life.  Such  lifelong  protection  is  sometimes 
conferred,  but  in  most  instances  the  protection  wears 
out  in  the  course  of  years  and  requires  to  be  renewed. 
The  period  of  protection  after  the  primary  vaccination 
is  scarcely  ever  less  than  five  years  and  not  infre- 
quently covers  a  period  of  from  ten  to  twenty  years. 
After  a  second  successful  vaccination,  the  individual 
is  in  the  majority  of  instances  protected  against  small- 
pox for  life. 

When  the  term  "vaccination"  is  employed,  a  success- 
ful vaccination  is  of  course  referred  to.  The  mere 
production  of  a  sore  arm  without  the  typical  course 
of  the  vaccine  affection  gives  no  protection  whatsoever. 
There  are  doubtless  many  persons  who  rest  under  the 
false  security  of  immunity  against  smallpox  in  whom 
genuine  vaccination  has  never  resulted,  and  who,  on 
exposure  to  smallpox,  would  take  the  disease. 

Unsuccessful  Vaccinations. — Occasionally  instances 
are  encountered  of  persons  who  have  been  vaccinated 
a  number  of  times,  but  never  successfully.  Sometimes 
these  persons  contract  severe  and  even  fatal  smallpox. 


Fisr.   10.— Father  and  child.     Child,  vaccinated,  escaped  the  disease. 


14 

One  such  case  was  a  physician  who  had  been  vaccin- 
ated seven  times  but  without  result.  Such  persons 
have  a  low  susceptibility  to  vaccinia  but  not  neces- 
sarily to  smallpox.  Commonly  a  good  active  vaccine 
virus  will  "take"  after  weaker  lymphs  have  failed. 


Fig.    11. — Mother   and    daughter.      The    daughter,    through   vaccination, 
although    exposed,    did    not    contract    the    disease. 

PROOF    OF    THE    EFFICACY    OF    VACCINATION 

Unanimity  of  Opinion  on  Vaccination. — Proof  of 
the  efficacy  of  vaccination  as  a  safeguard  against  small- 
pox is  based  on  more  than  a  century's  experience  with 
this  measure.     There  is  no  one  fact  in  medicine  which 


15 


is  more  conclusively  demonstrated.  Doctors  disagree 
on  many  things,  but  there  is  practical  unanimity  of 
opinion  on  the  value  of  vaccination.  There  are  a  few 
physicians  who  are  opposed  to  vaccination,  but  they 


Fig.   12. — Mother  seen  in   Figure  11,  front  view.     Typical  distribution 
of    eruption. 

constitute  but  a  minute  fraction  of  1  per  cent,  of  the 
profession.  There  is  no  medical  scientist  of  promi- 
nence in  the  United  States  who  is  not  an  ardent  advo- 
cate of  this  protective  measure. 


17 

Well  Protected  Countries. — Convincing  proof  of  the 
life-saving  power  of  vaccination  is  furnished  by  mas- 
sive statistics  gathered  from  Germany,  Cuba,  Porto 
Rico,  Philippine  Islands  and  other  countries  where 
vaccination  has  been  thoroughly  carried  out.  The 
statistical  evidence  of  the  efficacy  of  vaccination  is 
overwhelming,  but  space  will  not  permit  its  inclusion 
in  this  pamphlet. 

Crucial  Experiments  on  Monkeys. — Scientific  proof 
of  the  protective  power  of  vaccination  is  definitely 
established  by  tests  on  the  monkey,  the  only  animal 
besides  man  that  can  be  given  generalized  smallpox  by 
inoculation.  If  the  monkey  is  inoculated  with  small- 
pox virus,  he  acquires  a  mild  form  of  smallpox  of  the 
type  purposely  produced  in  the  eighteenth  century  to 
protect  people  against  the  more  severe  natural  small- 
pox. If,  however,  the  monkey  is  first  vaccinated,  it  is 
utterly  impossible  to  give  him  smallpox.  This  is  a 
complete  confirmation  of  the  tests  carried  out  by 
Jenner  and  others  on  human  subjects  more  than  a 
century  ago,  and  constitutes  evidence  of  the  most  irre- 
futable character  of  the  protective  value  of  vaccination 
against  smallpox. 

IMMUNITY    OF   VACCINATED    PHYSICIANS,    NURSES,    AND 
ATTENDANTS     IN     SMALLPOX     HOSPITALS 

If  it  can  be  demonstrated  that  physicians,  nurses  and 
attendants  in  smallpox  hospitals  can  be  perfectly  pro- 
tected by  vaccination,  then  this  must  be  regarded  as  a 
crucial  test  of  its  protective  influence ;  for  if  these  per- 
sons, living  in  the  same  atmosphere  with  scores  or  hun- 
dreds of  smallpox  patients,  breathing  their  very  exha- 
lations, are  enabled  to  escape  the  infection,  it  certainly 
should  be  possible  for  others  much  less  exposed  to 
acquire  similar  immunity. 

Protection  of  Persons  in  Smallpox  Hospitals. — 
Experience  shows  that  physicians,  nurses  and  attend- 
ants, if  recently  successfully  vaccinated  or  revacci- 
nated,  may  live  in  smallpox  hospitals  in  perfect  safety. 
Dr.  Marson,  physician  to  the  Smallpox  Hospital  of 
London  for  many  years,  giving  evidence  in  1871,  stated 
that  during  the  preceding  thirty-five  years  no  nurse  or 
servant  at  the  hospital  had  been  attacked  with  small- 
pox. Dr.  Marson  took  the  precaution  of  revaccinating 
all  attendants  before  permitting  them  to  go  on  duty. 


19 

Dr.  Collie,  whose  experience  is  also  large,  says :  "Dur- 
ing the  epidemic  of  1871,  out  of  one  hundred  smallpox 
attendants  at  Homerton  (England)  all  but  two  were 
revaccinated,  and  these  two  took  smallpox."  Dr. 
T.  F.  Ricketts,  medical  superintendent  of  the  smallpox 
hospital  ships  on  the  Thames,  states  that  out  of  1,201 
persons  in  attendance  on  board  the  smallpox  ships, 
only  six  contracted  the  disease,  all  of  them  recovering. 
None  of  these  six  persons  had  been  successfully  revac- 
cinated before  going  on  duty.  According  to  Dr.  Hill, 
of  Birmingham  (England),  during  the  epidemic  of 
1893,  over  one  hundred  persons  were  employed  at  the 
city  smallpox  hospital,  all  of  whom  had  been  recently 
revaccinated;  not  one  of  them  contracted  smallpox. 

Dr.  William  M.  Welch,  of  Philadelphia,  states  that 
in  the  Municipal  Hospital  of  Philadelphia  during  a 
period  of  thirty-four  years,  in  which  time  almost 
10,000  cases  of  smallpox  were  treated,  there  was  no 
instance  of  a  physician,  nurse  or  attendant,  who  had 
been  successfully  vaccinated  or  revaccinated  prior  to 
going  on  duty,  contracting  the  disease. 

IMMUNITY     OF     MEDICAL     STUDENTS     VISITING 
SMALLPOX     HOSPITALS 

Medical  Students  in  Chicago  and  Philadelphia. — In 
the  city  of  Chicago,  Dr.  Heman  Spalding  has,  since 
1899,  taken  thousands  of  medical  students  into  the 
wards  of  the  smallpox  hospitals  for  instruction  in 
diagnosis.  All  of  the  students  were  previously  vaccin- 
ated. Of  this  large  number  not  a  single  student  con- 
tracted the  disease.  From  1901  to  1904,  during  an 
epidemic  of  smallpox  in  Philadelphia,  about  700  med- 
ical students  were  taken  in  small  classes  through  the 
smallpox  wards  of  the  Municipal  Hospital.  But  one 
student  contracted  smallpox  and  he  had  evaded  vac- 
cination and,  indeed,  came  of  an  antivaccination 
family. 

ALLEGED    DANGERS    OF    VACCINATION 

Some  Risk  in  All  Human  Acts. — F-ery  human  act 
is  accompanied  by  some  measure  of  danger.  When 
one  rides  in  an  elevator,  in  a  railroad  car,  or  even 
promenades  on  the  sidewalk,  he  takes  a  certain  definite 
risk  which  can  be  mathematically  calculated.  While 
in  the  aggregate,  the  number  of  accidents  and  deaths 
from  each  of  these  causes  may  be  considerable,  yet  the 


21 

individual  risk  is  so  small  that  it  may  be  disregarded. 
It  is  the  same  with  reference  to  vaccination.  Inasmuch 
as  this  procedure  necessitates  the  production  of  an 
abrasion  or  wound,  it  naturally  is  liable  to  infections  to 
which  wounds  from  other  causes  are  subject.     Most 


Fig.  _  16. — Severe    smallpox,    showing    large    pustules.       (From    Acute 
Contagious   Diseases,    Welch   and    Schamberg.) 

of  these  infections  occur  in  persons  in  whom  regard 
for  cleanliness  and  for  the  subsequent  care  of  the  vac- 
cination are  neglected. 

Physicians  Well  Vaccinated  Class.— -If  there  is  any 
class  of  men  in  the  community  who  should  be  familiar 


22 


with  the  accidents  and  complications  of  vaccination,  it 
should  certainly  be  the  physicians.  With  this  knowl- 
edge in  their  possession,  medical  men  regard  vaccina- 
tion as  so  safe  a  procedure  that  they  almost  universally 
employ  this  measure  on  themselves,  their  wives  and 


Fig.  17. — An  unvaccinated  man,  exhibiting  the  development  of  a 
moderately  severe  attack  of  smallpox.  Third  day  of  eruption.  (From 
Acute   Contagious   Diseases,   Welch  and    Schamberg.) 

their  children.  Indeed,  physicians  and  their  families 
constitute  the  best  vaccinated  class  in  the  community. 
English  statistics  show  that  only  thirteen  medical  men 
per  million  die  of   smallpox   as   against  seventy-three 


23 


per  million  of  the  general  population.  The  contrast  is 
all  the  more  striking  in  view  of  the  fact  that  physicians 
are  more  exposed  to  smallpox  than  the  average  citizen. 
U.  S.  Public  Health  Service  Supervision. — Prac- 
tically all  of  the  accidents  of  vaccination  are  prevent- 


Fig.   18. — Fourth   day  of   eruption. 
Welch   and   Schamberg.) 


(From  Acute  Contagious  Diseases, 


able  by  the  selection  of  the  proper  virus  and  care  of 
the  arm  during  and  after  vaccination.  The  United 
States  Public  Health  Service  has  supervision  over  the 
products  of  vaccine  establishments  and  has  the  power 


24 


to  revoke  the  license  of  a  firm  placing  impure  virus 
on  the  market.  Frequent  examinations  of  virus  for 
purity  are  made  by  government  experts. 

The  danger  from  vaccination  has  been  enormously 
exaggerated  by  the  opponents  of  this  measure.  When 
we  consider  the  thousands  on  thousands  of  vaccina- 


Fig.    19. — Sixth    day    of   eruption. 
Welch   and    Schamberg.) 


(From    Acute    Contagious    Diseases, 


tions  performed,  even  on  the  unclean  and  under  unfa- 
vorable circumstances,  and  note  how  rare  it  is  for  any 
serious  complication  to  develop,  we  are  justified  in 
concluding  that  the  risk  attending  vaccination  in  any 
individual  case  is  practically  a  negligible  quantity.  The 
danger  connected  with  vaccination  is  slight  compared 
with  the  peril  of  remaining  unvaccinated. 


25 


Remarkable  Results  of  Vaccination  in  the  Philip- 
pines.— Dr.  Victor  G.  Heiser,  Sanitary  Director  of  the 
Philippine  Islands  (Report  of  the  Philippine  Commis- 
sion, and  of  the  Secretary  of  the  Interior,  part  2 
1907),  states  that,  up  to  1907,  over  2,000,000  humar 
beings  in  the  Philippines  had  been  vaccinated  by  the 


.,?&'  20- — Eighth  day  of  eruption.  (From  Acute  Contagious  Diseases, 
Welch  and   Schamberg.) 

United  States  authorities  without  the  loss  of  a  single 
life  or  limb  and  without  any  serious  case  of  infection. 
This_  remarkable  record  shows  what  a  safe  procedure 
vaccination  is. 

OPPOSITION     TO     VACCINATION 

Opponents  of  Vaccination  Not  Technically  Quali- 
fied.— The  reader  might  pertinently  ask,   If  vaccina- 


26 


tion  is  such  a  wonderful  preventive  against  a  loath- 
some, pestilential  disease,  why  should  there  be  any 
opposition  to  it?  People  have  a  natural  antipathy  to 
coercive  measures ;  this  applies  not  exclusively  to  vac- 
cination but  also  to  quarantine  and  forcible  removal 
to  the  hospital.  All  of  these  are  measures  designed 
for  the  public  welfare  and  come  within  the  exercise  of 


Fig.    21. — Twelfth    day    of    eruption.      (From    Acute    Contagious    Dis- 
eaeses,  Welch  and  Schamberg.) 

police  power.  As  a  matter  of  fact,  there  is  very  little 
opposition  to  vaccination  except  in  localities  where 
there  is  much  agitation  against  the  procedure.  If  some 
unfortunate  complication  follows  a  vaccination,  no 
matter  whether  or  not  it  be  due  to  neglect  on  the  part 
of  the  patient,  the  antivaccinationists  place  the  blame 
on  the  vaccine  virus.     The  opponents  of  vaccination  in 


27 


this  country  are  made  up  of  perfectly  sincere  but  woe- 
fully misguided  laymen,  who  are  not  qualified  by  tech- 
nical training  to  pass  judgment  on  a  medical  question, 
and  a  sprinkling  of  physicians  who  have  no  scientific 
sense  of  proportion.  The  great  physicians  and  the 
eminent  medical  scientists  of  the  country  are  as  a  unit 
in  favor  of  vaccination. 


Fig.  22. — Fourteenth  day  of  eruption. 
eases,  Welch  and  Schamberg.) 


(From  Acute   Contagious  Dis- 


Vaccination  Compulsory  in  All  Armies  and  Navies. 
— All  of  the  civilized  countries  of  the  world  have 
found  it  desirable  to  make  vaccination  compulsory  in 
their  armies  and  navies  and,  in  most  instances,  oblig- 
atory in  one  form  or  another  for  the  civil  population. 
Government  Commissions  in  England,  Denmark,  Ger- 
many and  the  United  States  which  were  appointed  to 
investigate  vaccination,  have  unqualifiedly  approved 
this  measure  as  a  safeguard  against  smallpox. 


28 


HOW     TO    AVOID    VERY     SORE    ARMS 

Improper  Care  of  Vaccinated  Arms. — Nearly  all 
very  sore  arms  and  the  vast  majority  of  the  complica- 
tions of  vaccination   are  due  to  maltreatment  of  the 


Fig.    23. — Sixteenth    day   of   eruption, 
eases,  Welch  and  Schamberg.) 


(From   Acute   Contagious   Dis- 


arm after  vaccination.  Many  children  injure  the  vac- 
cination through  rubbing,  scratching  or  other  violence 
resulting  in  tearing  off  of  the  scab  or  having  it  become 
adherent  to  the  underclothing.     Such  a  state  of  affairs 


29 


favors  increased  inflammation  and  infection  with 
various  germs,  and  is  the  most  fertile  cause  of  com- 
plications. These  cases  bring  vaccination  into  disre- 
pute; the  cause  of  the  trouble  is,  in  ninety-nine  out  of 
one  hundred  cases,  not  the  vaccine  virus,  but  the 
improper  care  of  the  arm  afterward.  Physicians 
should   therefore   give    more   detailed   information   to 


Fig.  24. — Appearance  of  patient  after  recovery.  Scarring  present 
but  not  deep.  (From  Acute  Contagious  Diseases,  Welch  and 
Schamberg.) 

parents  concerning  the  care  of  the  arm  after  vaccina 
tion.  Furthermore,  parents  should  be  told  what  symp- 
toms to  expect  after  vaccination  and  when  the  vaccin- 
ated subject  cannot  be  kept  under  observation  by  the 
physician,  they  should  report  to  him  any  undue  devel- 
opment in  the  vaccination. 


30 


COURSE    OF    VACCINATION 

1.  After  a  child  is  vaccinated  a  small  reddish  blood- 
crust  forms  at  the  site  of  the  abrasion. 

2.  About  the  fourth  day  the  inoculated  area  becomes 
reddened  and  is  slightly  raised  above  the  surface. 

3.  About  the  sixth  day  a  pearl-colored  flat  blister  or 
vesicle  is  formed,  containing  a  clear  fluid. 

4.  The  vaccination  reaches  its  height  about  thj 
eighth  or  ninth  day ;  there  is  a  flat  blister  with  a  dark 
central  caving  in;  around  the  blister  there  is  a  zone  of 
redness  with  some  swelling. 

5.  The  contents  of  the  vesicle  is  now  changed  to  a 
creamy  or  purulent  fluid;  the  glands  in  the  armpit 
become  tender  and  slightly  enlarged,  and  a  slight 
elevation  of  temperature  may  be  present  for  a  day 
or  two. 

6.  The  vesicle  now  becomes  darker  in  color  and  drier 
and  is  gradually  converted  into  a  hard  mahogany- 
colored  crust,  which  remains  attached  for  at  least  three 
weeks.  The  retention  of  this  crust  on  the  arm  until 
healing  has  taken  place  beneath  is  the  best  protection 
to  the  vaccination  site. 

CARE    OF    THE     ARM     AFTER    VACCINATION 

1.  Vaccination,  of  necessity,  produces  a  wound  on 
.he  skin ;  this  wound  may,  like  other  wounds,  become 
infected  with  various  germs  if  cleanliness  is  not 
)bserved. 

2.  Nearly  all  of  the  injuries  after  vaccination  are 
due  to  neglect  of  the  vaccination.  Germs  of  blood- 
poisoning,  and  even  those  of  lockjaw  may  get  into  the 
wound  if  the  vaccination  is  left  unprotected,  scratched 
or  comes  into  contact  with  dirty  clothes  and  the  like. 

3.  Shields  should  not  be  allowed  to  remain  on  the 
vaccination,  as  undue  inflammation  and  infection  may 
result.  A  small,  perforated,  linen  shield  may  be  placed 
over  the  vaccination  for  a  few  hours  until  it  dries.  It 
should  then  be  removed. 

4.  The  best  protection  to  a  vaccination  is  given  by 
the  application  of  a  half-dozen  layers  of  sterile  gauze 
(cheese-cloth,  3  by  4  inches,  wrapped  in  unprinted 
paper  and  baked  in  a  stove  oven  for  about  a  half-hour, 
will  suffice).  The  gauze  should  be  held  on  the  arm  by 
a  gauze  bandage  or  strips  of  adhesive  plaster. 


31 

_  5.  The  gauze  should  be  applied  shortly  after  vac- 
cination and  should  be  kept  on  constantly. 

6.  Clean  gauze  should  be  applied  every  few  days, 
according  to  circumstances.  The  person  changing  the 
dressing  should  thoroughly  scrub  the  hands  with  soap 
and  hot  water  beforehand. 


Fig.  25. — Severe  scarring  and  loss  of  hair  following  smallpox 
Patient  unvaccinated.  This  patient  also  lost  an  eye  from  the  disease. 
(From  Acute  Contagious  Diseases,  Welch  and  Schamberg.) 

7.  Care  should  be  taken  by  the  vaccinated  person  to 
avoid  having  the  arm  bruised  or  injured  in  any  way. 

8.  If  the  gauze  sticks  to  the  vaccination,  and  is  not 
easily  removed,  a  hot  2  per  cent,  solution  of  carbolic 
acid  in  water  or  similar  antiseptic  should  be  poured  on 
the  gauze  to  loosen  it. 


32 

9.  In  the  event  of  any  undue  inflammation  or  of  any 
illness  of  the  patient,  a  physician  should  be  consulted. 

10.  Patients  may  take  baths  in  a  tub  in  a  sitting 
position,  but  the  gauze  dressing  should  not  be  allowed 
to  get  wet. 

11.  An  excellent  method  of  treating  the  vaccination 
site  and  one  which  increases  the  comfort  of  the  sub- 


Fig.    26. — Destruction    of    eyeball    due    to    smallpox.      Patient    unvac- 
cinated.      (From   Acute  Contagious  Diseases,   Welch  and   Schamberg.) 

ject  and  lessens  inflammation  and  liability  of  infection, 
is  to  paint  over  and  around  the  vaccination  each  day 
(beginning  forty-eight  hours  after  vaccination)  a  2 
per  cent,  solution  of  picric  acid  in  70  per  cent,  alcohol. 
This  should  be  continued  daily  until  the  crust  has 
become  nuite  hard,  which  it  will  under  this  treatment 


33 


from  the  tenth  to  the  fifteenth  day.  Later,  carbolized 
vaseline  may  be  applied.  After  painting,  the  arm 
should  be  covered  with  gauze  and  a  bandage. 

HOW    TO    CONTROL    AND    PREVENT    SMALLPOX 

1.  Any  person  suspected  of  having  smallpox  should 
be  isolated  in  an  appropriate  apartment  and  no  one 
permitted  to  see  him  except  those  in  medical 
attendance. 

2.  The  proper  health  authorities  should  be  immedi- 
ately informed,  by  telephone  if  possible,  of  the  exist- 
ence of  a  smallpox  suspect. 


Fig.    27. — Destruction    of    eyeball    due    to    smallpox.      Patient    u 
cinated.      (From  Acute  Contagious   Diseases,  Welch  and   Schamberg,.  - 

s 

3.  If  the  case  proves  to  be  smallpox,  the  patieni  & 
should,  impossible,  be  immediately  removed  to  an  isola- 
tion hospital. 

4.  When  smallpox  is  first  suspected,  all  who  reside 
in  the  domicile  and  all  who  have  been  in  contact  with 
the  patient,  should  be  vaccinated  or  revaccinated. 

5.  Careful  inquiry  should  be  made  to  ascertain  the 
names  and  residence  of  all  "contacts,"  in  order  that 


34 


they  may  be  located  and  vaccinated  Otherwise 
numerous  foci  of  infection  may  be  established  and  lead 
to  a  widespread  epidemic. 

6  In  vaccinating  "contacts"  it  is  well  to  make  at 
least  two  insertions  of  the  lymph,  in  order  to  lessen  the 
chances  of  failure. 

7  If  the  smallpox  patient  is  sent  to  a  hospital,  the 
house  should  be  thoroughly  disinfected,  and  if  the  con- 
ditions warrant  the  inmates,  if  vaccinated  may  be 
allowed  their  freedom  under  surveillance  They  si hould 
be  most  carefully  examined  between  the  eighth  and 
eighteenth  days  after  the  first  exposure  Most  per- 
sons who  fall  ill,  exhibit  symptoms  about  eleven  days 
after  exposure,  although  with  the  prevailing  mild 
type"  the  incubation  may  be  longer  than  eighteen  days^ 

8  If  the  patient  is  treated  at  home,  the  house,  with 
all  of  the  inmates,  must  be  strictly  quarantined  until 
the  termination  of  the  case  and  disinfection  of  the 
premises. 

9  After  the  recovery  or  death  of  the  patient  the 
house  with  all  of  its  contents  should  be  disinfected  by 
formaldehyd.  The  mattress  on  which  the  patient  has 
lain  had  better  be  burned  if  facilities  are  not  at  hand 
to  disinfect  by  superheated  steam. 

10  School  children  residing  in  a  house  visited  by 
smalipox  should  not  return  to  school  without  author- 
ization from  the  school  or  health  authorities.  School 
or  library  books  should  not  be  returned  until  after 
special  disinfection. 

11  In  case  of  death,  the  body  should  be  wrapped  in 
trife:  saturated  with  1 :  500  mercuric  chlorid  solution, 

in  a  sealed  coffin  and  buried  within  twenty-four 
.  according  to  regulations  of  the  Board  of  Health 
fe  district.     Of  course,  no  public  funeral  services 
5  be  held  in  the  home  of  the  patient. 


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